[ABO gene subtypes and gene expression analysis in three cases of hematological malignancies patients]

Objective: To explore the application and discovery of genotyping, gene sequencing, and gene expression analysis in the determination of ABO blood group subtypes and antigen expression abnormalities in hematological malignancies patients. Methods: From June 2019 to May 2020, three clinical cases were found with forward and reverse ABO typing discrepancy or atypical serologic agglutination pattern in the laboratory and blood transfusion department of Hebei Yanda Ludaopei Hospital were selected. Sequence-specific primer PCR (PCR-SSP) and Sanger sequencing of ABO gene coding regions were performed to determine the ABO genotypes, and whole transcriptome sequencing was used to analyze ABO and FUT1 gene expression levels. Results: A 12-year-old female acute lymphoblastic leukemia patient was determined as O.01.02 and BA.04 sub-genotype, corresponding to the serological B(A) subtype, and her ABO gene expression was normal (354.80). A 41-year-old female acute myeloid leukemia patient was determined as A1.02 and B.01 genotype, corresponding to the serological A(1)B phenotype, and her ABO gene expression was significantly reduced (45.70). A 42-year-old male with myelodysplastic syndrome and myelofibrosis was determined as A1.02 and A2.05 sub-genotype, corresponding to the serological A(1) and A(2) phenotype, respectively, and his ABO expression was negative. FUT1 expression was in the normal range in all three cases. The clinical blood product infusion strategy was formulated according to the genotype and the corresponding immunological subtype, and no significant transfusion-related adverse reactions occurred. Conclusion: Blood group sub-genotypes or aberrant gene expression can lead to ambiguities in serological blood group determination in hematological malignancies patients. ABO genotyping and gene expression analysis can help in this scenario and escort blood product infusion safety.

Quantification and antioxidant and anti-HCV activities of the constituents from the inflorescences of Scabiosa comosa and S. tschilliensis

To investigate the bioactive constituents of the inflorescences of Scabiosa comosa and S. tschilliensis, which are used traditionally for liver diseases, we tested the antioxidant activity using 2,2'-diphenyl-1-picrylhydrazyl (DPPH), 2,2'-azinobis-(3-ethylbenzthiazoline-6-sulphonic acid) (ABTS), ferric reducing antioxidant potential (FRAP), and DPPH-ultra high performance liquid chromatography-mass spectrometer (UPLC-MS) assay. In addition, cell-based anti-HCV activity of the major compounds were evaluated. The plant extracts showed strong antioxidant activity. For the first time, 3,4-dicaffeoylquinic acid (DCQA), 3,5-DCQA and 4,5-DCQA were identified from genus Scabiosa. A UPLC-MS method in multiple reaction monitoring (MRM) mode was established to quantify 18 constituents in the inflorescences of Scabiosa. The 3,5-DCQA, chlorogenic acid and some glycosides of luteolin or apigenin were found to be the most abundant constituents. Chlorogenic acid and 3,5-DCQA showed excellent radical scavenging activity and demonstrated anti-HCV activity. These findings provided scientific evidences for the clinic use of this herbal medicine for liver diseases.

The management of imaging dose during image-guided radiotherapy: report of the AAPM Task Group 75

Radiographic image guidance has emerged as the new paradigm for patient positioning, target localization, and external beam alignment in radiotherapy. Although widely varied in modality and method, all radiographic guidance techniques have one thing in common--they can give a significant radiation dose to the patient. As with all medical uses of ionizing radiation, the general view is that this exposure should be carefully managed. The philosophy for dose management adopted by the diagnostic imaging community is summarized by the acronym ALARA, i.e., as low as reasonably achievable. But unlike the general situation with diagnostic imaging and image-guided surgery, image-guided radiotherapy (IGRT) adds the imaging dose to an already high level of therapeutic radiation. There is furthermore an interplay between increased imaging and improved therapeutic dose conformity that suggests the possibility of optimizing rather than simply minimizing the imaging dose. For this reason, the management of imaging dose during radiotherapy is a different problem than its management during routine diagnostic or image-guided surgical procedures. The imaging dose received as part of a radiotherapy treatment has long been regarded as negligible and thus has been quantified in a fairly loose manner. On the other hand, radiation oncologists examine the therapy dose distribution in minute detail. The introduction of more intensive imaging procedures for IGRT now obligates the clinician to evaluate therapeutic and imaging doses in a more balanced manner. This task group is charged with addressing the issue of radiation dose delivered via image guidance techniques during radiotherapy. The group has developed this charge into three objectives: (1) Compile an overview of image-guidance techniques and their associated radiation dose levels, to provide the clinician using a particular set of image guidance techniques with enough data to estimate the total diagnostic dose for a specific treatment scenario, (2) identify ways to reduce the total imaging dose without sacrificing essential imaging information, and (3) recommend optimization strategies to trade off imaging dose with improvements in therapeutic dose delivery. The end goal is to enable the design of image guidance regimens that are as effective and efficient as possible.

Energy optimization procedure for treatment planning with laser-accelerated protons

A simple analytical model is found that predicts the exact proton spectrum needed to obtain a spread-out-Bragg peak (SOBP) distribution for laser-accelerated proton beams. The theory is based on the solution to the Boltzmann kinetic equation for the proton distribution function. The resulting analytical expression allows one to calculate the SOBP proton energy spectra for the different beamlet sizes and modulation depths that can be readily implemented in the calculation of energy and intensity modulated proton dose distributions. Since the practical implementation of energy modulation for proton beams is realized through the discrete superposition of individual Bragg peaks, it is shown that there exists an optimal relationship between the energy sampling size and the width of the initial proton energy distribution.

New aristolochic acid, aristololactam and renal cytotoxic constituents from the stem and leaves of Aristolochia contorta

Two novel phenanthrene derivatives, aristololactam IVa (1) and 9-hydroxy aristolochic acid I (2) were isolated from the stem and leaves of Anstolochia contorta Bunge, together with 17 known compounds (3-19). The structures of these compounds were determined by spectroscopic analysis. The phenanthrenes obtained were tested for cytotoxicity against renal proximal tubular epithelial cell line (HK-2). Aristololactam IVa and 7-methoxy aristololactam IV were found to have strong cytotoxic activity against HK-2 cells with a potency similar to or even stronger than those of aristolochic acid I and aristololactam I.

Dosimetry validation of treatment room shielding design

Intensity-modulated radiation therapy (IMRT) can lead to an increase in leakage radiation. The total number of monitor units (MUs) for IMRT is typically 2-5 times that for conventional treatments [the ratio of the two is used to derive the effective modulation scaling factor (MSFeff)]. Shielding calculations for IMRT can be done by applying the MSFeff to measured exposures under conservative conditions (standard beam setup 40 cm x 40 cm field, 45 degrees collimator angle) to account for the increased leakage. In this work, we verified this approach for two existing vaults housing a Siemens Primart 6 MV linac and a Varian 21Ex 10 MV linac. We measured the cumulative exposures at various locations around the vaults for typical IMRT cases and for the standard beam setup using the same MUs. For the standard beam setup, the IMRT gantry angles and eight equally spaced angles were used. Estimations of weekly exposures for IMRT were carried out using exposure rates measured under standard beam setup and the MSFeff averaged over 20 treatment cases. The accumulated exposures under realistic IMRT conditions were 30%-50% lower than the estimated values using equally spaced gantry angles except for two locations where the real IMRT leakage was higher than the estimated value by approximately 10%. Measurements using the same gantry angles yielded similar results. Our results indicate that it is adequate to use the MSFeff and previously measured exposures to estimate the leakage increase due to IMRT for an existing vault. Different approaches should be followed when considering primary or secondary barriers since the standard beam setup is overestimating the exposures behind primary barriers compared to IMRT. In such cases, a 10 cm x 10 cm field can be used for more accurate shielding evaluation.

Modelling of electron contamination in clinical photon beams for Monte Carlo dose calculation

The purpose of this work is to model electron contamination in clinical photon beams and to commission the source model using measured data for Monte Carlo treatment planning. In this work, a planar source is used to represent the contaminant electrons at a plane above the upper jaws. The source size depends on the dimensions of the field size at the isocentre. The energy spectra of the contaminant electrons are predetermined using Monte Carlo simulations for photon beams from different clinical accelerators. A 'random creep' method is employed to derive the weight of the electron contamination source by matching Monte Carlo calculated monoenergetic photon and electron percent depth-dose (PDD) curves with measured PDD curves. We have integrated this electron contamination source into a previously developed multiple source model and validated the model for photon beams from Siemens PRIMUS accelerators. The EGS4 based Monte Carlo user code BEAM and MCSIM were used for linac head sinulation and dose calculation. The Monte Carlo calculated dose distributions were compared with measured data. Our results showed good agreement (less than 2% or 2 mm) for 6, 10 and 18 MV photon beams.

Commissioning 6 MV photon beams of a stereotactic radiosurgery system for Monte Carlo treatment planning

The goal of this work is to implement a beam commissioning procedure to generate a multiple source model using a set of standard measurement data for possible Monte Carlo treatment planning in the clinic for a Cyberknife stereotactic radiosurgery system. The required measurement data include the central axis depth dose curve (PDD), the dose profile at dmax(= 1.5 cm) of 60 mm cone at 80 cm source-to-surface distance (SSD), and the cone output factors for cones of 5 mm to 60 mm at 80 cm source-to-axis distance (SAD). The employed dual source model has the same structure as the one that has been studied in our previous work while most of the parameters of each source are extracted from the measurement data rather than the beam phase space. The energy spectra will be extracted from the central axis PDD, the fluence distributions will be deconvoluted from the dose profile at dmax, and the source distributions will be determined from the measured cone output factors. Monte Carlo dose calculations in various water phantoms have been performed to verify the beam commissioning procedure. The agreement between the measurements and the commissioning results was within 2%/1 mm for the central axis PDDs and the dose profiles at various depths when an IC-3 chamber was used and within 2% for the cone output factors for various collimator sizes of 5 to 60 mm. Largest difference (9.5%) was observed for the 7.5 mm cone when an IC-10 chamber was used. The large differences can be attributed to the volumetric averaging effect of the IC-10 chamber, whose dimension is comparable to the field of the small cones. The overall agreement between the measurements and the commissioning results is clinically acceptable, which implies that our commissioning tool is adequate for clinical applications of Monte Carlo dose calculations for the Cyberknife stereotactic radiosurgery system.

Optimization of combined electron and photon beams for breast cancer

Recently, intensity-modulated radiation therapy and modulated electron radiotherapy have gathered a growing interest for the treatment of breast and head and neck tumours. In this work, we carried out a study to combine electron and photon beams to achieve differential dose distributions for multiple target volumes simultaneously. A Monte Carlo based treatment planning system was investigated, which consists of a set of software tools to perform accurate dose calculation, treatment optimization, leaf sequencing and plan analysis. We compared breast treatment plans generated using this home-grown optimization and dose calculation software for different treatment techniques. Five different planning techniques have been developed for this study based on a standard photon beam whole breast treatment and an electron beam tumour bed cone down. Technique 1 includes two 6 MV tangential wedged photon beams followed by an anterior boost electron field. Technique 2 includes two 6 MV tangential intensity-modulated photon beams and the same boost electron field. Technique 3 optimizes two intensity-modulated photon beams based on a boost electron field. Technique 4 optimizes two intensity-modulated photon beams and the weight of the boost electron field. Technique 5 combines two intensity-modulated photon beams with an intensity-modulated electron field. Our results show that technique 2 can reduce hot spots both in the breast and the tumour bed compared to technique 1 (dose inhomogeneity is reduced from 34% to 28% for the target). Techniques 3, 4 and 5 can deliver a more homogeneous dose distribution to the target (with dose inhomogeneities for the target of 22%, 20% and 9%, respectively). In many cases techniques 3, 4 and 5 can reduce the dose to the lung and heart. It is concluded that combined photon and electron beam therapy may be advantageous for treating breast cancer compared to conventional treatment techniques using tangential wedged photon beams followed by a boost electron field.

Clinical implementation of intensity-modulated tangential beam irradiation for breast cancer

A Monte Carlo based intensity-modulated radiation therapy (IMRT) treatment planning system has been developed and used for breast treatment. An iterative method was used for optimization to generate IMRT plans and a step-and-shoot technique was used for beam delivery. The patient setup and incident beam directions were the same as those for conventional tangential photon treatment. The weights for the opposed beamlets in the two tangential beams were determined first by the doses at the depths of the maximum dose at both sides to minimize hot spots. The intensity of an individual beamlet pair was then optimized based on the dose at the midplane. Fine tuning was made to achieve optimal target dose uniformity and to reduce the dose to the heart when necessary. The final dose calculations were performed using the Monte Carlo method and the plans were verified by phantom measurements. The dose distributions and dose-volume-histograms of IMRT plans were compared with those of conventional plans that were generated using a commercial treatment planning system and recalculated using an in-house Monte Carlo system for the first 25 patients. The dose comparisons showed that the percentage volume receiving more than 95% of the prescription dose (V95) and the percentage volume receiving more than 100% of the prescription dose (V100) for the clinical target volume (CTV) of IMRT plans were about the same as those of conventional plans. The percentage volume receiving more than 105% of the prescription dose (V105) for the CTV was reduced from 23.1% to 7.9% on average. The percentage volume of the lung receiving more than 20 Gy dose (V20 Gy) during the entire treatment was reduced by about 10%. The percentage volume of the heart receiving more than 30 Gy dose (V30 Gy) is reduced from 3.3% to 0.3%. Further studies revealed that a less than 5 degrees change in couch angle and collimator angle at patient setup had no significant effect on the dose coverage of CTV but had significant effect on the dose to the lung and heart. The study on the effect of beam spoiler showed that it increased the dose at the buildup region by 0- 13% that varies with location. The machine output linearity and stability for small monitor unit delivery of Siemens accelerators used for this study was checked and found to be suitable for breast IMRT. The total effect of variations was calculated to be less than 1% for typical breast treatments. The beam delivery time was increased by about 2 min compared with conventional tangential treatments. The whole treatment including patient setup and beam delivery can be completed in a 15 min slot. The IMRT technique has been proven practical for breast treatment clinically. The results showed that tangential IMRT improved the dose homogeneity in the breast and reduced the dose to the lung and heart.

Monitor unit calculation for Monte Carlo treatment planning

In this work, we investigate a formalism for monitor unit (MU) calculation in Monte Carlo based treatment planning. By relating MU to dose measured under reference calibration conditions (central axis, depth of dose maximum in water, 10 cm x 10 cm field defined at 100 cm source-to-surface distance) our formalism determines the MU required for a treatment plan based on the prescription dose and Monte Carlo calculated dose distribution. Detailed descriptions and formulae are given for various clinical situations including conventional treatments and advanced techniques such as intensity-modulated radiotherapy (IMRT) and modulated electron radiotherapy (MERT). Analysis is made of the effects of source modelling, beam modifier simulation and patient dose calculation accuracy, all of which are important factors for absolute dose calculations using Monte Carlo simulations. We have tested the formalism through phantom measurements and the predicted MU values were consistent with measured values to within 2%. The formalism has been used for MU calculation and plan comparison for advanced treatment techniques such as MERT, extracranial stereotactic IMRT, MRI-based treatment planning and intensity-modulated laser-proton therapy studies. It is also used for absolute dose calculations using Monte Carlo simulations for treatment verification, which has become part of our comprehensive IMRT quality assurance programme.

Modelling 6 MV photon beams of a stereotactic radiosurgery system for Monte Carlo treatment planning

The goal of this work is to build a multiple source model to represent the 6 MV photon beams from a Cyberknife stereotactic radiosurgery system for Monte Carlo treatment planning dose calculations. To achieve this goal, the 6 MV photon beams have been characterized and modelled using the EGS4/BEAM Monte Carlo system. A dual source model has been used to reconstruct the particle phase space at a plane immediately above the secondary collimator. The proposed model consists of two circular planar sources for the primary photons and the scattered photons, respectively. The dose contribution of the contaminant electrons was found to be in the order of 10(-3) of the total maximum dose and therefore has been omitted in the source model. Various comparisons have been made to verify the dual source model against the full phase space simulated using the EGS4/BEAM system. The agreement in percent depth dose (PDD) curves and dose profiles between the phase space and the source model was generally within 2%/1 mm for various collimators (5 to 60 mm in diameter) at 80 to 100 cm source-to-surface distances (SSD). Excellent agreement (within 1%/1 mm) was also found between the dose distributions in heterogeneous lung and bone geometry calculated using the original phase space and those calculated using the source model. These results demonstrated the accuracy of the dual source model for Monte Carlo treatment planning dose calculations for the Cyberknife system.

Daily target localization for prostate patients based on 3D image correlation

There are several localization techniques that have been used for prostate treatment. Recently, the potential use of a variety of CT-based equipment in the treatment room has been discussed. The goal of our study was to develop an automated procedure for daily treatment table shift calculation based on two CT data sets: simulation CT data and localization CT data. The method suggested in this study is a 3D image cross-correlation of small regions of interest (ROI) within the two data sets. The relative position of the two ROIs with respect to each other is determined by the maximum value of the normalized cross-correlation function, calculated for all possible relative locations of the two ROIs. After the best match is found the shifts are given by the vector connecting the treatment isocentre and the planning isocentre (both determined by the radio opaque fiducial markers on the patient's skin). The results have been compared with shifts calculated through manual fusion. The shift differences, averaged over 17 statistically independent shift calculations, are less then 1 mm in the lateral and longitudinal directions, and about 1 mm in the AP direction. The impact of image noise on the performance of the algorithm has been tested. The results show that the algorithm accurately adjusts for target positional changes even with Gaussian noise levels as high as 20% inserted.

Intensity modulated radiation therapy using laser-accelerated protons: a Monte Carlo dosimetric study

In this paper we present Monte Carlo studies of intensity modulated radiation therapy using laser-accelerated proton beams. Laser-accelerated protons coming out of a solid high-density target have broad energy and angular spectra leading to dose distributions that cannot be directly used for therapeutic applications. Through the introduction of a spectrometer-like particle selection system that delivers small pencil beams of protons with desired energy spectra it is feasible to use laser-accelerated protons for intensity modulated radiotherapy. The method presented in this paper is a three-dimensional modulation in which the proton energy spectrum and intensity of each individual beamlet are modulated to yield a homogeneous dose in both the longitudinal and lateral directions. As an evaluation of the efficacy of this method, it has been applied to two prostate cases using a variety of beam arrangements. We have performed a comparison study between intensity modulated photon plans and those for laser-accelerated protons. For identical beam arrangements and the same optimization parameters, proton plans exhibit superior coverage of the target and sparing of neighbouring critical structures. Dose-volume histogram analysis of the resulting dose distributions shows up to 50% reduction of dose to the critical structures. As the number of fields is decreased, the proton modality exhibits a better preservation of the optimization requirements on the target and critical structures. It is shown that for a two-beam arrangement (parallel-opposed) it is possible to achieve both superior target coverage with 5% dose inhomogeneity within the target and excellent sparing of surrounding tissue.

Dose correlation for thoracic motion in radiation therapy of breast cancer

This work investigates the dose correlation for deformed objects due to thoracic motion for radiotherapy treatment of breast cancer. An analytical model has been developed to reconstruct patient anatomy based on the assumption that the body will expand or compress proportionally during respiration. The patient geometry at any phase during a breathing pattern is reconstructed using the CT data taken at the inspiration and expiration phases and the breathing level which can be related to the measured chest wall motion. A correlation between the voxels in the inspiration (or expiration) geometry and the voxels in the reconstructed geometry at any phase of the breathing pattern is established so that the dose can be accumulated during a treatment. The method has been implemented for treatment planning dose calculation by interfacing with a Monte Carlo code. The patient geometry files for different phases of the breathing pattern are generated and the three-dimensional dose data are obtained from the Monte Carlo simulations. The final dose distribution is reconstructed from the dose data at different breathing phases based on patient's breathing pattern associated with chest wall movements.

Particle selection for laser-accelerated proton therapy feasibility study

In this paper we present calculations for the design of a particle selection system for laser-accelerated proton therapy. Laser-accelerated protons coming from a thin high-density foil have broad energy and angular spectra leading to dose distributions that cannot be directly used for therapeutic applications. Our solution to this problem is a compact particle selection and collimation device that delivers small pencil beams of protons with desired energy spectra. We propose a spectrometer-like particle selection and beam modulation system in which the magnetic field will be used to spread the protons spatially according to their energies and emitting angles. Subsequently, an aperture will be used to select the protons within a therapeutic window of energy (energy modulation). It will be shown that for the effective proton spatial differentiation, the primary collimation device should be used, which will collimate protons to the desired angular distribution and limit the spatial mixing of different energy protons once they have traveled through the magnetic system. Due to the angular proton distribution, the spatial mixing of protons of different energies will always be present and it will result in a proton energy spread with the width depending on the energy. For 250 MeV protons, the width (from the maximum to the minimum energy) is found to be 50 MeV for the magnetic field configuration used in our calculations. As the proton energy decreases, its energy width decreases as well, and for 80 MeV protons it equals 9 MeV. The presence of the energy width in the proton energy distribution will modify the depth dose curves needed for the energy modulation calculation. The matching magnetic field setup will ensure the refocusing of the selected protons and the final beam will be collimated by the secondary collimator. The calculations presented in this article show that the dose rate that the selection system can yield is on the order of D=260 Gy/min for a field size of 1 x 1 cm2.

A comparative dosimetric study on tangential photon beams, intensity-modulated radiation therapy (IMRT) and modulated electron radiotherapy (MERT) for breast cancer treatment

Recently, energy- and intensity-modulated electron radiotherapy (MERT) has garnered a growing interest for the treatment of superficial targets. In this work. we carried out a comparative dosimetry study to evaluate MERT, photon beam intensity-modulated radiation therapy (IMRT) and conventional tangential photon beams for the treatment of breast cancer. A Monte Carlo based treatment planning system has been investigated, which consists of a set of software tools to perform accurate dose calculation, treatment optimization, leaf sequencing and plan analysis. We have compared breast treatment plans generated using this home-grown treatment optimization and dose calculation software forthese treatment techniques. The MERT plans were planned with up to two gantry angles and four nominal energies (6, 9, 12 and 16 MeV). The tangential photon treatment plans were planned with 6 MV wedged photon beams. The IMRT plans were planned using both multiple-gantry 6 MV photon beams or two 6 MV tangential beams. Our results show that tangential IMRT can reduce the dose to the lung, heart and contralateral breast compared to conventional tangential wedged beams (up to 50% reduction in high dose volume or 5 Gy in the maximum dose). MERT can reduce the maximum dose to the lung by up to 20 Gy and to the heart by up to 35 Gy compared to conventional tangential wedged beams. Multiple beam angle IMRT can significantly reduce the maximum dose to the lung and heart (up to 20 Gy) but it induces low and medium doses to a large volume of normal tissues including lung, heart and contralateral breast. It is concluded that MERT has superior capabilities to achieve dose conformity both laterally and in the depth direction, which will be well suited for treating superficial targets such as breast cancer.

A quality assurance phantom for IMRT dose verification

This paper investigates a quality assurance (QA) phantom specially designed to verify the accuracy of dose distributions and monitor units (MU) calculated by clinical treatment planning optimization systems and by the Monte Carlo method for intensity-modulated radiotherapy (IMRT). The QA phantom is a PMMA cylinder of 30 cm diameter and 40 cm length with various bone and lung inserts. A procedure (and formalism) has been developed to measure the absolute dose to water in the PMMA phantom. Another cylindrical phantom of the same dimensions, but made of water, was used to confirm the results obtained with the PMMA phantom. The PMMA phantom was irradiated by 4, 6 and 15 MV photon beams and the dose was measured using an ionization chamber and compared to the results calculated by a commercial inverse planning system (CORVUS, NOMOS, Sewickley, PA) and by the Monte Carlo method. The results show that the dose distributions calculated by both CORVUS and Monte Carlo agreed to within 2% of dose maximum with measured results in the uniform PMMA phantom for both open and intensity-modulated fields. Similar agreement was obtained between Monte Carlo calculations and measured results with the bone and lung heterogeneity inside the PMMA phantom while the CORVUS results were 4% different. The QA phantom has been integrated as a routine QA procedure for the patient's IMRT dose verification at Stanford since 1999.

Particle in cell simulation of laser-accelerated proton beams for radiation therapy

In this article we present the results of particle in cell (PIC) simulations of laser plasma interaction for proton acceleration for radiation therapy treatments. We show that under optimal interaction conditions protons can be accelerated up to relativistic energies of 300 MeV by a petawatt laser field. The proton acceleration is due to the dragging Coulomb force arising from charge separation induced by the ponderomotive pressure (light pressure) of high-intensity laser. The proton energy and phase space distribution functions obtained from the PIC simulations are used in the calculations of dose distributions using the GEANT Monte Carlo simulation code. Because of the broad energy and angular spectra of the protons, a compact particle selection and beam collimation system will be needed to generate small beams of polyenergetic protons for intensity modulated proton therapy.

A Monte Carlo investigation of fluence profiles collimated by an electron specific MLC during beam delivery for modulated electron radiation therapy

Modulated electron radiation therapy (MERT) is able to deliver conformal dose to shallow tumors while significantly reducing dose to distal structures and surrounding tissues. An electron specific multileaf collimator (eMLC) has been proposed and constructed as an effective means of delivering electron beams for MERT. The aim of this work is to apply the Monte Carlo method to investigate the fluence profiles collimated by the eMLC in order to achieve accurate beam delivery for MERT. In this work, the EGS4/BEAM code was used to simulate the eMLC collimated electron beams of 6-20 MeV generated from a Varian Clinac 2100C linear accelerator. An attempt was made to describe the fluence profiles with an analytic Sigmoid function. The function parameters were determined by the fittings of the Monte Carlo simulated fluence profiles. How the function parameters depend on the eMLC aperture size, the off-axis location, and the electron beam energy has been investigated. It has been found that the eMLC collimated fluence profiles are dependent on beam energy, while almost independent of leaf location or dimension of MLC aperture. There is little difference in the fluence profiles collimated by the leaf side and the leaf end for the straight-edged leaves. It is possible that these energy-dependent Sigmoid functions can serve as operators to account for the energy dependence of the eMLC collimated fluence profiles. These operators can be incorporated into the inverse planning algorithm to derive desired dose distributions using a set of electron beams of variable energy and field size suitable for delivery by the eMLC.

Monte Carlo simulation for MLC-based intensity-modulated radiotherapy

This article describes photon beam Monte Carlo simulation for multi leaf collimator (MLC)-based intensity-modulated radiotherapy (IMRT). We present the general aspects of the Monte Carlo method for the non-Monte Carloist with an emphasis given to patient-specific radiotherapy application. Patient-specific application of the Monte Carlo method can be used for IMRT dose verification, inverse planning, and forward planning in conventional conformal radiotherapy. Because it is difficult to measure IMRT dose distributions in heterogeneous phantoms that approximate a patient, Monte Carlo methods can be used to verify IMRT dose distributions that are calculated using conventional methods. Furthermore, using Monte Carlo as the dose calculation method for inverse planning results in better-optimized treatment plans. We describe both aspects and present our recent results to illustrate the discussion. Finally, we present current issues related to clinical implementation of Monte Carlo dose calculation. Monte Carlo is the most recent, and most accurate, method of radiotherapy dose calculation. It is currently in the process of being implemented by various treatment planning vendors and will be available for clinical use in the immediate future.

A Monte Carlo dose calculation tool for radiotherapy treatment planning

A Monte Carlo user code, MCDOSE, has been developed for radiotherapy treatment planning (RTP) dose calculations. MCDOSE is designed as a dose calculation module suitable for adaptation to host RTP systems. MCDOSE can be used for both conventional photon/electron beam calculation and intensity modulated radiotherapy (IMRT) treatment planning. MCDOSE uses a multiple-source model to reconstruct the treatment beam phase space. Based on Monte Carlo simulated or measured beam data acquired during commissioning, source-model parameters are adjusted through an automated procedure. Beam modifiers such as jaws, physical and dynamic wedges, compensators, blocks, electron cut-outs and bolus are simulated by MCDOSE together with a 3D rectilinear patient geometry model built from CT data. Dose distributions calculated using MCDOSE agreed well with those calculated by the EGS4/DOSXYZ code using different beam set-ups and beam modifiers. Heterogeneity correction factors for layered-lung or layered-bone phantoms as calculated by both codes were consistent with measured data to within 1%. The effect of energy cut-offs for particle transport was investigated. Variance reduction techniques were implemented in MCDOSE to achieve a speedup factor of 10-30 compared to DOSXYZ.

Verification of IMRT dose distributions using a water beam imaging system

A water beam imaging system (WBIS) has been developed and used to verify dose distributions for intensity modulated radiotherapy using dynamic multileaf collimator. This system consisted of a water container, a scintillator screen, a charge-coupled device camera, and a portable personal computer. The scintillation image was captured by the camera. The pixel value in this image indicated the dose value in the scintillation screen. Images of radiation fields of known spatial distributions were used to calibrate the device. The verification was performed by comparing the image acquired from the measurement with a dose distribution from the IMRT plan. Because of light scattering in the scintillator screen, the image was blurred. A correction for this was developed by recognizing that the blur function could be fitted to a multiple Gaussian. The blur function was computed using the measured image of a 10 cm x 10 cm x-ray beam and the result of the dose distribution calculated using the Monte Carlo method. Based on the blur function derived using this method, an iterative reconstruction algorithm was applied to recover the dose distribution for an IMRT plan from the measured WBIS image. The reconstructed dose distribution was compared with Monte Carlo simulation result. Reasonable agreement was obtained from the comparison. The proposed approach makes it possible to carry out a real-time comparison of the dose distribution in a transverse plane between the measurement and the reference when we do an IMRT dose verification.

Monte Carlo based treatment planning for modulated electron beam radiation therapy

A Monte Carlo based treatment planning system for modulated electron radiation therapy (MERT) is presented. This new variation of intensity modulated radiation therapy (IMRT) utilizes an electron multileaf collimator (eMLC) to deliver non-uniform intensity maps at several electron energies. In this way, conformal dose distributions are delivered to irregular targets located a few centimetres below the surface while sparing deeper-lying normal anatomy. Planning for MERT begins with Monte Carlo generation of electron beamlets. Electrons are transported with proper in-air scattering and the dose is tallied in the phantom for each beamlet. An optimized beamlet plan may be calculated using inverse-planning methods. Step-and-shoot leaf sequences are generated for the intensity maps and dose distributions recalculated using Monte Carlo simulations. Here, scatter and leakage from the leaves are properly accounted for by transporting electrons through the eMLC geometry. The weights for the segments of the plan are re-optimized with the leaf positions fixed and bremsstrahlung leakage and electron scatter doses included. This optimization gives the final optimized plan. It is shown that a significant portion of the calculation time is spent transporting particles in the leaves. However, this is necessary since optimizing segment weights based on a model in which leaf transport is ignored results in an improperly optimized plan with overdosing of target and critical structures. A method of rapidly calculating the bremsstrahlung contribution is presented and shown to be an efficient solution to this problem. A homogeneous model target and a 2D breast plan are presented. The potential use of this tool in clinical planning is discussed.

Inhibitory effects on HIV-1 protease of tri-p-coumaroylspermidine from Artemisia caruifolia and related amides

From a methanol extract of Artemisia caruifolia, which showed a moderate inhibitory activity on HIV-1 protease in a preliminary screening, N1,N5,N10-tri-p-coumaroylspermidine and three dicaffeoylquinic acids were isolated. The former compound was found to appreciably inhibit HIV-1 protease. Of related amides which were chemically synthesized, N1,N5,N10,N14-tetra-p-coumaroylspermine and N1,N4,N7,N10,N13-penta-p-coumaroylte-traethylenepentamine inhibited HIV-1 protease more potently than N1,N5,N10-tri-p-coumaroylspermidine.

AAPM protocol for 40-300 kV x-ray beam dosimetry in radiotherapy and radiobiology

The American Association of Physicists in Medicine (AAPM) presents a new protocol, developed by the Radiation Therapy Committee Task Group 61, for reference dosimetry of low- and medium-energy x rays for radiotherapy and radiobiology (40 kV < or = tube potential < or = 300 kV). It is based on ionization chambers calibrated in air in terms of air kerma. If the point of interest is at or close to the surface, one unified approach over the entire energy range shall be used to determine absorbed dose to water at the surface of a water phantom based on an in-air measurement (the "in-air" method). If the point of interest is at a depth, an in-water measurement at a depth of 2 cm shall be used for tube potentials > or = 100 kV (the "in-phantom" method). The in-phantom method is not recommended for tube potentials < 100 kV. Guidelines are provided to determine the dose at other points in water and the dose at the surface of other biological materials of interest. The protocol is based on an up-to-date data set of basic dosimetry parameters, which produce consistent dose values for the two methods recommended. Estimates of uncertainties on the final dose values are also presented.

Kaempferol acetylrhamnosides from the rhizome of Dryopteris crassirhizoma and their inhibitory effects on three different activities of human immunodeficiency virus-1 reverse transcriptase

Three new kaempferol glycosides, called crassirhizomosides A (1), B (2) and C (3), were isolated from the rhizome of Dryopteris crassirhizoma (Aspidiaceae), together with the known kaempferol glycoside, sutchuenoside A (4). The structures of 1-3 were determined as kaempferol 3-alpha-L-(2,4-di-O-acetyl)rhamnopyranoside-7-alpha-L-rhamnopyranoside, kaempferol 3-alpha-L-(3,4-di-O-acetyl)rhamnopyranoside, and kaempferol 3-alpha-L-(2,3-di-O-acetyl)rhamnopyranosside-7-alpha-L-rhamnopyranoside, respectively, by chemical and spectroscopic means. Inhibitory effects of 1-4 and kaempferol on human immunodeficiency virus reverse transcriptase-associated DNA polymerase (RNA-dependent DNA polymerase and DNA-dependent DNA polymerase) and RNase H activities were investigated.

Derivation of electron and photon energy spectra from electron beam central axis depth dose curves

A method for deriving the electron and photon energy spectra from electron beam central axis percentage depth dose (PDD) curves has been investigated. The PDD curves of 6, 12 and 20 MeV electron beams obtained from the Monte Carlo full phase space simulations of the Varian linear accelerator treatment head have been used to test the method. We have employed a 'random creep' algorithm to determine the energy spectra of electrons and photons in a clinical electron beam. The fitted electron and photon energy spectra have been compared with the corresponding spectra obtained from the Monte Carlo full phase space simulations. Our fitted energy spectra are in good agreement with the Monte Carlo simulated spectra in terms of peak location, peak width, amplitude and smoothness of the spectrum. In addition, the derived depth dose curves of head-generated photons agree well in both shape and amplitude with those calculated using the full phase space data. The central axis depth dose curves and dose profiles at various depths have been compared using an automated electron beam commissioning procedure. The comparison has demonstrated that our method is capable of deriving the energy spectra for the Varian accelerator electron beams investigated. We have implemented this method in the electron beam commissioning procedure for Monte Carlo electron beam dose calculations.

The MLC tongue-and-groove effect on IMRT dose distributions

We have investigated the tongue-and-groove effect on the IMRT dose distributions for a Varian MLC. We have compared the dose distributions calculated using the intensity maps with and without the tongue-and-groove effect. Our results showed that, for one intensity-modulated treatment field, the maximum tongue-and-groove effect could be up to 10% of the maximum dose in the dose distributions. For an IMRT treatment with multiple gantry angles (> or = 5), the difference between the dose distributions with and without the tongue-and-groove effect was hardly visible, less than 1.6% for the two typical clinical cases studied. After considering the patient setup errors, the dose distributions were smoothed with reduced and insignificant differences between plans with and without the tongue-and-groove effect. Therefore, for a multiple-field IMRT plan (> or = 5), the tongue-and-groove effect on the IMRT dose distributions will be generally clinically insignificant due to the smearing effect of individual fields. The tongue-and-groove effect on an IMRT plan with small number of fields (< 5) will vary depending on the number of fields in a plan (coplanar or non-coplanar), the MLC leaf sequences and the patient setup uncertainty, and may be significant (> 5% of maximum dose) in some cases, especially when the patient setup uncertainty is small (< or = 2 mm).

Induction of tumor necrosis factor receptor type 2 gene expression by tumor necrosis factor-alpha in rat primary astrocytes

Using reverse transcription-polymerase chain reaction (RT-PCR) technique, the messenger RNA (mRNA) for tumor necrosis factor receptor type 2 (TNF-R2, 75/80 kDa) was detected in rat primary astrocytes, with much lower level of expression when compared to that for tumor necrosis factor receptor type 1 (TNF-R1, 55/60 kDa). Upon exposure to TNF-alpha (100 U/ml), the TNF-R2 mRNA level was greatly enhanced at 8 h, while TNF-R1 mRNA remained unchanged even after 24 h. The induction of TNF-R2 gene expression by TNF-alpha was dose-dependent and seemed to be unique to TNF-alpha, as interleukin-6 (IL-6) had no significant effect on TNF-R2 expression. Since TNF-R2 was reported to mediate mitogenic and gene-inducing effects in many other cell types, it is likely that the reported proliferative effect of TNF-alpha on astrocytes was also mediated by this TNF receptor subtype. Upon exposure to TNF-alpha or lipopolysaccharide (LPS), the expression of TNF-alpha gene was induced, and the LPS-induced TNF-alpha seemed to selectively enhance the TNF-R2 gene expression. Collectively, our results suggest that the TNF-alpha or LPS-induced expression of both TNF-R2 and TNF-alpha may provide a positive control mechanism to further enhance the proliferative effect of TNF-alpha in astrocytes.

Five saponins from the root bark of Aralia elata

Five saponins, 3-O-[beta-D-glucopyranosyl (1-->2)-[beta-D-glucopyranosyl (1-->3)]-beta-D-glucopyranosyl]-oleanolic acid 28-O-beta-D-glucopyranosyl ester (aralia-saponin V), 3-O-[beta-D-glucopyranosyl (1-->2)-[beta-D-glucopyranosyl (1-->3)]-beta-D-glucopyranosyl]-echinocystic acid 28-O-beta-D-glucopyranosyl ester (aralia-saponin VI), 3-O-beta-D-glucopyranosyl (1-->2)-[beta-D-glucopyranosyl (1-->3)]-beta-D-glucopyranosyl]-hederagenin 28-O-beta-D-glucopyranosyl ester (aralia-saponin VII), 3-O-[beta-D-glucopyranosyl-(1-->3)-beta-D-glucopyranosyl-(1-->3)-[beta-D-glucopyranosyl-(1-->2)]-beta-D-glucopyranosyl]-caulophyllogenin 28-O-beta-D-glucopyranosyl ester (aralia-saponin VIII), 3-O-[beta-D-glucopyranosyl (1-->2)-[beta-D-glucopyranosyl(1-->3)]-alpha-L-arabinopyranosyl]-hederagenin 28-O-beta-D-glucopyranosyl ester (aralia-saponin IX), were isolated from the root bark of Aralia elata (Miq.) Seem., together with four known compounds. Their structures were determined on the basis of chemical and spectroscopic methods.

Triterpenes and lignans from Artemisia caruifolia and their cytotoxic effects on meth-A and LLC tumor cell lines

One new triterpene, 3beta-hydroxy-29-norcycloart-24-one (1), and four new lignans, caruilignans (2-5), together with six known compounds were isolated from the aerial part of Artemisia caruifolia BUCH.-HAM. ex TOXB. Their structures were determined by various spectroscopic means. Most of the isolated lignans were moderately cytotoxic to Meth-A cells with ED50 values of 5-10 microg/ml, but not to Lowis lung carcinoma (LLC) cells. An oxime derivative of 1 showed more potent cytotoxic activity against Meth-A and LLC cells than the original triterpene 1.

Modeling the extrafocal radiation and monitor chamber backscatter for photon beam dose calculation

A simple analytical approach has been developed to model extrafocal radiation and monitor chamber backscatter for clinical photon beams. Model parameters for both the extrafocal source and monitor chamber backscatter are determined simultaneously using conventional measured data, i.e., in-air output factors for square and rectangular fields defined by the photon jaws. The model has been applied to 6 MV and 15 MV photon beams produced by a Varian Clinac 2300C/D accelerator. Contributions to the in-air output factor from the extrafocal radiation and monitor chamber backscatter, as predicted by the model, are in good agreement with the measurements. The model can be used to calculate the in-air output factors analytically, with an accuracy of 0.2% for symmetric or asymmetric rectangular fields defined by jaws when the calculation point is at the isocenter and 0.5% when the calculation point is at an extended SSD. For MLC-defined fields, with the jaws at the recommended positions, calculated in-air output factors agree with the measured data to within 0.3% at the isocenter and 0.7% at off-axis positions. The model has been incorporated into a Monte Carlo dose algorithm to calculate the absolute dose distributions in patients or phantoms. For three MLC-defined irregular fields (triangle shape, C-shape, and L-shape), the calculations agree with the measurements to about 1% even for points at off-axis positions. The model will be particularly useful for IMRT dose calculations because it accurately predicts beam output and penumbra dose.

Monte Carlo and experimental investigations of multileaf collimated electron beams for modulated electron radiation therapy

Modulated electron radiation therapy (MERT) has been proposed as a means of delivering conformal dose to shallow tumors while sparing distal structures and surrounding tissues. Conventional systems for electron beam collimation are labor and time intensive in their construction and are therefore inadequate for use in the sequential delivery of multiple complex fields required by MERT. This study investigates two proposed methods of electron beam collimation: the use of existing photon multileaf collimators (MLC) in a helium atmosphere to reduce in-air electron scatter, and a MLC specifically designed for electron beam collimation. Monte Carlo simulations of a Varian Clinac 2100C were performed using the EGS4/BEAM system and dose calculations performed with the MCDOSE code. Dose penumbras from fields collimated by photon MLCs both with air and with helium at 6, 12, and 20 MeV at a range of SSDs from 70 to 90 cm were examined. Significant improvements were observed for the helium based system. Simulations were also performed on an electron specific MLC located at the level of the last scraper of a 25x25 cm2 applicator. A number of leaf materials, thicknesses, end shapes, and widths were simulated to determine optimal construction parameters. The results demonstrated that tungsten leaves 15 mm thick and 5 mm wide with unfocused ends would provide sufficient collimation for MERT fields. A prototype electron MLC was constructed and comparisons between film measurements and simulation demonstrate the validity of the Monte Carlo model. Further simulations of dose penumbras demonstrate that such an electron MLC would provide improvements over the helium filled photon MLC at all energies, and improvements in the 90-10 penumbra of 12% to 45% at 20 MeV and 6 MeV, respectively. These improvements were also seen in isodose curves when a complex field shape was simulated. It is thus concluded that an MLC specific for electron beam collimation is required for MERT.

Validation of a Monte Carlo dose calculation tool for radiotherapy treatment planning

A new EGS4/PRESTA Monte Carlo user code, MCDOSE, has been developed as a routine dose calculation tool for radiotherapy treatment planning. It is suitable for both conventional and intensity modulated radiation therapy. Two important features of MCDOSE are the inclusion of beam modifiers in the patient simulation and the implementation of several variance reduction techniques. Before this tool can be used reliably for clinical dose calculation, it must be properly validated. The validation for beam modifiers has been performed by comparing the dose distributions calculated by MCDOSE and the well-benchmarked EGS4 user codes BEAM and DOSXYZ. Various beam modifiers were simulated. Good agreement in the dose distributions was observed. The differences in electron cutout factors between the results of MCDOSE and measurements were within 2%. The accuracy of MCDOSE with various variance reduction techniques was tested by comparing the dose distributions in different inhomogeneous phantoms with those calculated by DOSXYZ without variance reduction. The agreement was within 1.0%. Our results demonstrate that MCDOSE is accurate and efficient for routine dose calculation in radiotherapy treatment planning, with or without beam modifiers.

Monte Carlo characterization of clinical electron beams in transverse magnetic fields

Monte Carlo simulations were employed to study the characteristics of the electron beams of a clinical linear accelerator in the presence of 1.5 and 3.0 T transverse magnetic fields and to assess the possibility of using magnetic fields in conjunction with modulated electron radiation therapy (MERT). The starting depth of the magnetic field was varied over several centimetres. It was found that peak doses of as much as 2.7 times the surface dose could be achieved with a 1.5 T magnetic field. The magnetic field was shown to reduce the 80% and 20% dose drop-off distance by 50% to 80%. The distance between the 80% dose levels of the pseudo-Bragg peak induced by the magnetic field was found to be extremely narrow, generally less than 1 cm. However, by modulating the energy and intensity of the electron fields while simultaneously moving the magnetic field, a homogeneous dose distribution with low surface dose and a sharp dose fall-off was generated. Heterogeneities are shown to change the effective range of the electron beams, but not eliminate the advantages of a sharp depth dose drop-off or high peak-to-surface dose ratio. This suggests the applicability of MERT with magnetic fields in heterogeneous media. The results of this study demonstrate the ability to use magnetic fields in MERT to produce highly desirable dose distributions.

Monte Carlo verification of IMRT dose distributions from a commercial treatment planning optimization system

The purpose of this work was to use Monte Carlo simulations to verify the accuracy of the dose distributions from a commercial treatment planning optimization system (Corvus, Nomos Corp., Sewickley, PA) for intensity-modulated radiotherapy (IMRT). A Monte Carlo treatment planning system has been implemented clinically to improve and verify the accuracy of radiotherapy dose calculations. Further modifications to the system were made to compute the dose in a patient for multiple fixed-gantry IMRT fields. The dose distributions in the experimental phantoms and in the patients were calculated and used to verify the optimized treatment plans generated by the Corvus system. The Monte Carlo calculated IMRT dose distributions agreed with the measurements to within 2% of the maximum dose for all the beam energies and field sizes for both the homogeneous and heterogeneous phantoms. The dose distributions predicted by the Corvus system, which employs a finite-size pencil beam (FSPB) algorithm, agreed with the Monte Carlo simulations and measurements to within 4% in a cylindrical water phantom with various hypothetical target shapes. Discrepancies of more than 5% (relative to the prescribed target dose) in the target region and over 20% in the critical structures were found in some IMRT patient calculations. The FSPB algorithm as implemented in the Corvus system is adequate for homogeneous phantoms (such as prostate) but may result in significant under or over-estimation of the dose in some cases involving heterogeneities such as the air-tissue, lung-tissue and tissue-bone interfaces.

Removing the effect of statistical uncertainty on dose-volume histograms from Monte Carlo dose calculations

Dose-volume histograms (DVHs) of the dose distributions calculated by the Monte Carlo method contain statistical uncertainties. The Monte Carlo DVH can be considered as blurred from the noiseless DVH by the statistical uncertainty. The focus of the present work is on the removal of the statistical uncertainty effect on the Monte Carlo DVHs and the reconstruction of the noiseless DVHs. We first study the effect of statistical uncertainty. It is found that the steeper the DVH, the more significant the effect. For typical critical structure DVHs the effect is usually negligible. For the target DVHs the effect could be clinically significant, depending on the value of uncertainty and the slope of the DVH. We then propose an iterative reconstruction algorithm. Using the DVHs and statistical uncertainties from the Monte Carlo simulations, we are able to reconstruct the noiseless DVHs. A hypothetical example and a number of clinical cases have been used to test the proposed algorithm. For each clinical case, two Monte Carlo simulations (denoted A and B) were performed. Simulation A has very large statistical uncertainties (about 10% of dose in the target volume) while simulation B has very small uncertainties (about 1%). DVHs from simulation B were used to approximate the noiseless DVHs. Using the proposed algorithm, the effect of statistical uncertainty can be removed from the DVHs of simulation A. The reconstructed DVHs were in good agreement with the DVHs from simulation B. The proposed approach is expected to be useful in removing the blurring effect on a quickly calculated Monte Carlo DVH when performing the iterative forward treatment planning.

Biotransformation of a C-glycosylflavone, abrusin 2''-O-beta-D-apioside, by human intestinal bacteria

After anaerobic incubation of abrusin 2''-O-beta-D-apioside (1) with a human fecal suspension, five metabolites were isolated and identified as abrusin (2), 1-(2',6'-dihydroxy-3',4'-dimethoxyphenyl)-3-(4''-hydroxyphenyl)propan-1- one (5), 5,6-dimethoxybenzene-1,3-diol (6), 3-(4'-hydroxyphenyl)propionic acid (7) and 3-phenylpropionic acid (8). However, methyl ether derivatives of abrusin (4'-O-methylabrusin and 4'-O-, 5-O-dimethylabrusin) resisted degradation under the same conditions.

Calculation of x-ray transmission through a multileaf collimator

A ray tracing based method has been developed to calculate the x-ray transmission through a multileaf collimator (MLC) for beam delivery verification and dose calculation in intensity modulated radiotherapy (IMRT). The path length of a ray line in the MLC is accurately calculated using the exact geometry of the MLC leaves. The fluence distribution of an IMRT field is calculated first using a point source. The fluence distribution for a realistic beam model is obtained, as an approximation, by convolving the point source fluence distribution with the distribution of source strength. Full ray tracing calculations are performed using analytic and Monte Carlo simulated beam models to verify the accuracy of the convolution method. The calculation is in better agreement with measurements using either film or a beam imaging system (BIS) than previous calculations for MLC transmission using a simplified model. This ray tracing calculation can be applied to the problem of verifying dynamic MLC leaf sequences as part of a patient-specific quality assurance process for IMRT.

Energy- and intensity-modulated electron beams for radiotherapy

This work investigates the feasibility of optimizing energy- and intensity-modulated electron beams for radiation therapy. A multileaf collimator (MLC) specially designed for modulated electron radiotherapy (MERT) was investigated both experimentally and by Monte Carlo simulations. An inverse-planning system based on Monte Carlo dose calculations was developed to optimize electron beam energy and intensity to achieve dose conformity for target volumes near the surface. The results showed that an MLC with 5 mm leaf widths could produce complex field shapes for MERT. Electron intra- and inter-leaf leakage had negligible effects on the dose distributions delivered with the MLC, even at shallow depths. Focused leaf ends reduced the electron scattering contributions to the dose compared with straight leaf ends. As anticipated, moving the MLC position toward the patient surface reduced the penumbra significantly. There were significant differences in the beamlet distributions calculated by an analytic 3-D pencil beam algorithm and the Monte Carlo method. The Monte Carlo calculated beamlet distributions were essential to the accuracy of the MERT dose distribution in cases involving large air gaps, oblique incidence and heterogeneous treatment targets (at the tissue-bone and bone-lung interfaces). To demonstrate the potential of MERT for target dose coverage and normal tissue sparing for treatment of superficial targets, treatment plans for a hypothetical treatment were compared using photon beams and MERT.